Tag Archives: journal club

Croup: Riding the Dex Express

Sooooo….this paper turned up at JC last week (thanks to Nicola P) and whilst I’m not sure that it meets all three of our criteria for a top JC paper it is relevant as a week barely seems to go by without someone questioning the dose/route/brand/colour/size/ethnicity of medicine for croup.
Rule of thumb chaps and chapesses ‘The greater the dogma, the greater the ignorance’. Someone cleverer than I said that, but I’m happy to plagiarise ‘cos it’s true.
Anyway, Croup arrives as a question once again in the journal Emergency Medicine Australia, but this time the question relates to speed of onset in mild to moderate croup.

 STOP! If you are in exam mode at this point you should read the paper. See what you think about it and give it a mark out of 10.

We’ve talked about this paper and it’s a tricky one. The first question is why has this paper been done (which we cannot answer, but can surmise privately). The use of steroids in the management of croup is very well established and is something we led on here in Virchester many years ago. It was even one of the very first BETs back in 2004 (amazing to think that we are still talking about this 8 years later).
I’ve also seen the Cochrane review and even examined some CTRs for FCEM on the subject. So, it pretty much seems to me that the question of whether we give steroids for croup is well made. The research that remains is, I suppose, about refining and polishing what is surely a well established fact.

STEROIDS WORK IN CROUP Click the link and read the Cochrane review.

So, what about the paper this week? Is there anything we can draw from it and learn? Well, the authors have done an RCT (good) on mild/moderate croup patients. Interesting this as for the mild ones would you give steroids or just let nature take its course? (Ed – depends on how mild as croup score 1-3 is mild) I’m not sure so there maybe an element of over-treatment in comparison to other practices. Whatever, the authors tell us that there is an effect of giving steroids that they can define and detect at  30 minutes following administration of steroid and that this counteracts the information given through Cochrane about a delayed effect taking up to 6 hours.

I have major concerns with this paper and I just don’t see how this is going to make a significant difference to our practice in PEM.  I don’t think a paper like this would appear in an exam, but if it did I would be pulling holes in it along the following lines.

1. What is the clinically important question here? It seems that we are looking to see the speed of onset of steroid meds in mild/moderate croup. The clinical importance of this is perhaps unclear except in logistical (admission) terms. What defines a significant difference in this low acuity group? Mild croup is not admitted anyway so what is the issue we are addressing?

2. Sample size. OK. An interest of mine, and if you share that interest (you sad person) then hop over to the podcast to hear more about how to understand and interpret sample size calculations. In this paper they appear to be using tests for continuous data for data which is unlikely to be so. Honestly, it seems as though these are the wrong tests for this data, but there is insufficient information in the paper for us to tell. Where is the clue? Well, the Wesley croup score is a categorical score (at best ordinal). It’s not continuous and is unlikely to be normally distributed, so a t-test is rarely going to be the right test. So hmm, not enough information to know but questions are there to be asked. If you want to know more about stats for Critical Appraisal then click here and here. Apart from anything else, a study of just 70 patients would have to show a massive effect if it is be valid and I don’t see that here. Similarly the graph shows average scores only, and I’m not sure that I’m just interested in the change in average score amongst 35 patients. I want to see the distribution as well. This is a common problem in papers as the mean score reporting removes the depth and character of the data.

3. Right, so we are unsure of the validity of the question and also of the sample size what else? Well,  do applaud the authors for defining the numbers of patients that they ‘could’ have recruited and the difference between that number (828) and the number recruited (70) is huge. This suggests a degree of patient selection which may well affect the results. Now, I don’t want to put a massive downer on this as it is an inevitable problem with EM research, but this ratio really asks questions as to whether this is a representative sample, or whether the results will be heavily skewed because it is a sample of convenience.

So, it sounds as though we were pretty down on this paper from a methodological point of view. We gave it a 3/10 to be honest which is clearly not high, but just wait is there ANYTHING we can take away from this piece of work at all. Well, it’s tricky to be honest. It’s likely (but I’m finding it difficult to tell) that oral dex starts working fairly quickly, but that was never a clinical dilemma for me before I read this paper so I’m not going to change practice. However, it’s a useful to use this as a vehicle to discuss Croup (again), to review the relevant BETs and to talk about how to spot flaws in papers.

 bw

Simon C

PS. If you are still in exam mode try answering the following questions…

1. What is meant by the term ‘double-blinded’ and why is it important in a trial like this?

2. Four patients in the placebo group worsened during the initial phase of the trial and were then given steroids. They were analysed in the placebo group despite getting steroids. What is this type of analysis called and is it the right approach?

Journals are dead: Long live the Journal Club

“The report of my death was an exaggeration”

Mark Twain

Just a quicky and a link out to our guide on Emergency Medicine Journal Clubs. Despite the rumours of the imminent demise of all medical journals, we at @stemlyns strongly believe that this will not lead to the death of journal clubs. Even if paper publication wanes (and it probably will) it will be even more important for clinicians to have the skills and abilities to be wary of what ‘evidence’ is out there.

For example anyone can now set up a Blog (Er, not sure that’s the right message here – Ed) and say what they like. How do you know it’s fair comment and good enough to change practice?

You do need, and you will always need to be a sceptic with the skills to critically appraise and critique the evidence and we think that a Journal Club is a great way to learn.

Read more here on our top tips for making your Emergency Medicine Journal Club effective, productive and worthwhile.

Our Journal Club runs on a Friday lunchtime in the ED. We’ll review, debate and then blog on the papers we discuss. Watch the blog for the latest in EM Critical Appraisal.

vb

Simon C

PS: We’ll be keeping a log of papers reviewed in our Journal Club from now on. If it works then we should have a rolling program of the best, most current and most relevant papers for Emergency Medicine. If you’re coming up to an exam….it’s a good place to visit.

The wise thirsts for questions, not answers!

The following post displays comments from tweets about speakers at the 14th ICEM in Dublin in June 2012.

Some reflect evidence-based medicine, some just personal practice supported by expert opinion only.

We post these in order to generate reflection and lateral thinking.

Remember: The wise thirsts for questions, not answers!

Ruben Strayer:

Cricoid pressure is futile during during RSI

Modified/delayed RSI in order to improve pre-oxygenation prior to paralysis: sub-naesthetic dose of ketamine in agitated patient to allow oxygenation

A failed cricothyroidotomy performed at the right time is defensible but a successful one perfomed too late is indefensible

Apneic oxygenation: leave the nasal cannula on the patient while you are intubating (oxygen diffusion)

Ron Walls:

Is it ethical to teach direct laryngoscopy on critically ill patients given the superiority of video devices?

Emanuel Rivers:

52% of septic patients are coming from EDs but the mortality is the lowest in this group when compared to those originating from somewhere else

What is important is not the amount of fluid you give but how quick you give it

10% of septic patients have a normal lactate

Lactate as a marker of severity is great but in conjunction with other markers of sepsis

EGDT better late than never!

Ian Stiell:

Today’s EPs are not interested in EBM unless in the format of an app or in less than 140 characters

Tim Harris:

Urgent thoracotomy is to be performed in witnessed traumatic cardiac arrest. If you cannot do one, you should not be receiving trauma

Major trauma is rare and it is therefore difficult to become an expert

Tim Coats:

Gelofusine impedes coagulation more than normal saline

Mattu:

Chest pains in the elderly is associated with belching in 47% of cases

Cameron: 

Victoria immobilizes 50,000 C-spines for 20 unstable fractures per year

Greg Henry:

Management is doing things right, leadership is knowing the right things to do

Cadogan:

The purpose of research is to induce change, not to get published!

Jones:

Epinephrine is the second agent of choice after norepinephrine in sepsis (or vasopressin)

Cantor:

Procedural sedation good quality indicator of an ED

Greg Henry:

Give good news in public, criticise in private. Compliment ten times more than you criticise

Unattributed:

Midline bony tenderness lacks sensitivity and specificity for cervical fractures (U/K)

CT scan sensitivity for spinal injury 98% vs x-rya 58% (data from trauma centres) (U/K)

Anaphylaxis in the patient on beta-blockers: add glucagon –it will activate cGMP directly (U/K)

Since the 2005 ALS guidelines, the survival of OHCA has risen from 27% to 50% (U/K)

One needs to read 17 articles/day to keep current in EBM (U/K)

Patients with high BP post-arrest do better: it improves cerebral micro-circulation (U/K)

Experimental evidence suggests that therapeuthic hypothermia best started within 5 hours of the arrest (U/K)

If you are an idiot offline, you will be an idiot online (U/K)

If you have no internet presence at all then anyone can control your internet presence (U/K)

The visual connection with the patient is essential. If the physician cannot see the patient, the patient stays longer in ED (U/K)

If you train exclusively in one country, you will not appreciate where EM is globally! (U/K)

There is pressure on EPs to give up some of their work because there is not enough of them. Does anyone else do it better? No! (U/K)

We agree that children are not just small adults. But older children do behave like adults in trauma! (U/K)

Traumatic cardiac arrest: no adrenaline, no CPR.  O2, ventilate cautiously, bilateral thoracotomy! (U/K)

Recognising ambulatory care sensitive cases: a solution to overcrowding? (U/K)

 

Tweets collected by Janos P Baombe